Memorandum submitted by Naz Foundation
International
1. EXECUTIVE
SUMMARY
1.1 Male to male sex in South Asia is diverse,
with many males who have sex with males (MSM) having indigenous,
no, or to a much lesser extent, western style identities.
1.2 Gender identity is also important in
relation to male to male sex in South Asia.
1.3 High levels of HIV risk taking behaviour
between males in South Asia is evident.
1.4 We find high levels of HIV amongst some
MSM populations (estimated to be a 10% HIV prevalence in India),
to emerging epidemics in others (estimated to be a 2% HIV prevalence
in Pakistan, and a 1% HIV prevalence in Bangladesh).
1.5 High levels of untreated sexually transmitted
infections and genito-urinary complaints further increase HIV
acquisition and transmission risk.
1.6 Stigma and discrimination of MSM leads
to their increased vulnerability to HIV.
1.7 Provision of appropriate HIV related
services for MSM in South Asia is relatively new.
1.8 Whilst there has been some development
of services, not all services are appropriate.
1.9 Support for appropriate HIV interventions
for MSM from national governments in the region vary.
1.10 Coverage of HIV services for MSM is
not well understood, but we estimate this to be poor, certainly
for care and support services for MSM infected with HIV.
1.11 DFID, the EU, the UN and NGOs have
a role to play in ensuring universal access to appropriate HIV
services for MSM in South Asia, by policy development, advocacy,
financial and other support.
1.12 DFID should continue to support the
strategic development of appropriate MSM HIV services in South
Asia, continue to, and increase support to MSM HIV interventions
in the region, and to ensure these activities are sustained.
1.13 DFID needs to provide leadership and
support to UNAIDS and others, to ensure universal access to HIV
services for MSM in South Asia.
1.14 DFID needs to allocate financial resources
in accordance with the priority it gives to MSM and HIV in its
HIV strategy to ensure the issue is appropriately addressed, and
to ensure that this strategy meets the needs of MSM and HIV.
1.15 This committee should ask DFID to assess
the coverage of MSM and HIV related services in South Asia, how
their current HIV strategy will ensure universal access to HIV
services for MSM, and what changes they might need to make to
their strategy to ensure this universal access.
2. INTRODUCTION
TO SUBMITTER
2.1 I have been working on HIV and AIDS
issues since 1989. I have a wide range of experience of working
on HIV and AIDS issues which includes:
— Developing a syringe exchange
scheme for injecting drug users in London, providing clean injecting
equipment and information on safer injecting practices.
— Working with people with same
gender attraction from minority ethnic, providing information
on HIV, AIDS and safer sex.
— Developing services for minority
ethnic communities, providing information, advice, counselling
and support around HIV and AIDS in the UK, and providing support
for this work across Europe.
— Developing, and advocating for
appropriate HIV related services for males who have sex with males
in Asia, other resource-poor settings and elsewhere.
— Advocating for microbicides
and other new HIV prevention technologies.
2.2 I have particular expertise in a number
of areas related to HIV, which are:
— Understanding behaviour, identity
and HIV risk factors of MSM in South Asia and elsewhere.
— Designing, developing, supporting
and implementing HIV prevention and support, particularly for
hard to reach communities, both in the UK and in resource-poor
settings, particularly in South Asia.
— Advocacy and policy development
around HIV related prevention, support and care for MSM in South
Asia and elsewhere.
3. FACTUAL INFORMATION
3.1 For drawing conclusions from, or putting
to other witnesses.
3.2 Holding the UK Government to account
for the commitment it made during 2005 to support international
efforts, led by UNAIDS, to achieve the goal of universal access
to HIV/AIDS prevention, treatment, care and support for all those
who need it, by 2010. The provision of HIV/AIDS prevention, treatment,
care and support to males who have sex with males in South Asia.
Our knowledge of the contribution of DFID in addressing these
issues, and the role of the EU, UN and non-governmental organisations.
3.2.1 Our current knowledge of the HIV epidemics
amongst males who have sex with males (MSM) in South Asia. Identity,
behaviour and HIV risk factors. The role of male to male sex in
wider-population level epidemics.
3.2.1.1 The existence of male to male sex
in South Asia has often been denied, although the work of the
Naz Foundation International[17]
and others, has documented wide-spread male to male sex, across
social, economic and religious line in South Asia. As in the West,
there are MSM who take on a "gay" identity, but these
tend to be richer, middle class men, who live in major urban areas,
and are able to resist marriage. For the remainder of MSM in South
Asia, they tend to be married, and to exhibit a range of sexualities,
genders and behaviours. Our research has shown both indigenous
and developing sexualities of males in this region. For example,
in South Asia, we find many MSM who, whilst married, and taking
on a male identity when with their wife, cross-dress, wear make-up,
and take on "feminine" mannerisms, with a view to finding
"manly" sexual partners. They even have their own identity,
kothi in India, zenana in Pakistan, and meti
in Nepal. Their male sexual partners though usually have no specific
identity related to their male to male sex practices, although
the kothis in India label them as panthis. The kothis
in India also have a term for a man they deem to be their male
husband, a parik. The point here being that, we find both
established indigenous differing identities, and non-identifying
MSM. Kothis and their equivalent elsewhere, tend not to
have formed communities, but have tended to be isolated from each
other. In South Asia, we also find communities of MSM who cross-dress
all the time, take on a "feminine" identity, but usually
identify as not a man or a women, but a third gender. In India
they are known as hijra. Hijra live in closely knit
communities, with a guru, heading up a clan of chela
(her disciples). There can be many such communities in an urban
area in South Asia. Boys and young men who join a hijra
communities will certainly cross-dress, and many of them will
be castrated, usually by member of the hijra community,
and there is anecdotal evidence that castration practices are
increasing. Hijras have sex with other males, either for
pleasure, for money, or because they are forced to. Both kothis
and hijras (and their equivalents elsewhere in South Asia)
tend to be sexually penetrated. As mentioned before, both kothis
and hijras tend to have sex with those who do not identify
as an MSM, and there is a growing body of evidence that suggests
that male to male sex in South Asia is very common. For example,
a study of truck drivers in Lahore, Pakistan, showed that 49%
had had sex with another male[18],
often this sex would be with their male help or a male sex worker.
3.2.1.2 From our assessments[19],
we find high levels of unprotected anal sex between feminised
males and other males. Also we have evidence that kothis
are more highly sexed with their female partners than non-kothi
males. As mentioned earlier, the kothis and hijras
tend to be anally penetrated. Other male to male sexual behaviour,
such as oral sex, masturbation, and thigh sex, where the penis
is placed between the (usually the feminised) male's thighs, and
rubbed to and fro are commonly found. We also find that many of
these marginalised, and here we refer to kothis, hijras
and their like, often have many sexual partners. For example,
in recent study in Sylhet, Bangladesh, 20% of the MSM we talked
to had had between 11 and 15 male sexual partners in the last
month. In addition to sex for pleasure, many of the marginalised
males sell sex for cash and favours, or are forced on many occasions
to have sex (by the police, local thugs etc). We find relatively
low levels of condom use in areas where there have been no, or
little HIV related interventions specifically for MSM. In the
same study just referred to, condoms were used in only 31% of
anal receptive sex acts. We find this is in part due to lack of
access to condoms and suitable lubricant, discrimination against
those who carry these by the police and others (male to male sex
is illegal across South Asia), lack of knowledge regarding HIV
transmission, and low self-esteem, meaning that many MSM do not
care if they become infected with HIV or not. These marginalised
males often find sexual partners in public "cruising"
sites, such as parks, toilets and railway tracks, which offer
some fairly private place to go and have sex. Other sex between
males is almost encouraged by the very homosocial spaces we find
in South Asia, where brothers, cousins, uncles etc, share beds
with other males, males work together, and all-male institutions
such as the military, prisons etc are common. We have reports
of much situational male to male sex occurring, although often
this sex is as hidden as it can be, and usually not discussed.
3.2.1.3 In terms of male to male sex, and
the risk of acquiring or transmitting HIV, there are a number
of risk factors:
— The high levels of unprotected
anal sex we find amongst MSM.
— The high numbers of sexual partners
we find amongst MSM.
— High levels of sexually transmitted
infections (STIs), and other genito-urinary diseases (GUDs). For
example, in all of our studies, we find MSM populations with high
levels of untreated STIs and GUDs, or where treated, this is usually
self-treated, often poorly. STIs and GUDs have been shown to heighten
the risk of acquiring HIV.
— High levels of stigma and discrimination
against MSM and male to male sex. This results in discrimination
against males who show feminine characteristics at home, at school
and in the workplace, resulting in lower self-esteem, lower educational
achievements, and lower chances of sufficiently economic employment.
This leads often to sex work, as a means of survival, with associated
risks of acquiring HIV from multiple partners, lack of consistent
condom use and sexual abuse. More information on stigma and discrimination
around male to male sex and its effect on HIV vulnerability can
be found in a recent study and report we undertook on behalf of
the British Foreign and Commonwealth Office, looking at this issue
in India and Bangladesh, and a copy of this report entitled "From
the front line" can be obtained on our website[20].
3.2.2 Provision of HIV related services
for MSM in South Asia so far and in the future.
3.2.2.1 When we started addressing male
to male sex and HIV issues in South Asia in 1996, there were very
few interventions addressing this issue. What existed, often focussed
on forwarding a "gay" agenda, and was mainly restricted
to more wealthy middle class males in urban areas in India. We
have since 1996 though, helped establish over 50 community based
interventions addressing MSM and HIV issues in the region. Together
with this, other individuals and organisations have established
HIV related services that target MSM in the region. We use a community
development model, where we identify interested MSM in a particular
area, train them on undertaking a needs assessment with respect
to MSM and HIV in their local area, work with them to undertake
this needs assessment, then help them develop and maintain a community
based organisations to respond to these and changing needs. Many
of these organisations have been successful in obtaining funds
to continue their work from the local government (in India), international
private sources, or bilateral donor aid. Initially these community
based organisations (CBOs) were based in their state, or in the
case of Bangladesh and Nepal, country capitals. With support from
my organisation, we have helped these organisations expand their
operations in other cities and areas in their states/countries,
to increase coverage of services to MSM. Since March 2006, with
support from DFID in India, we have been scaling up MSM and HIV
related interventions in four states in India (Andra Pradesh,
Karnataka, Tamil Nadu, and Uttar Pradesh), developing nine new
MSM CBOs providing MSM and HIV interventions in each of these
states. In addition to the stigma and discrimination study undertaken
in India and Bangladesh, we developed the capacity of a number
of CBOs in India and Bangladesh to form working groups to monitor
human rights abuses for MSM, and to also deal with these issues
at national levels. This work is ongoing, and DFID India is supporting
this work there. In our studies, we find that most condoms were
not used with a suitable water-based lubricant, which is essential
to ensure they afford appropriate protection. There are a number
of reasons for this, in part due to the cost of the then available
lubricants, the fact that carrying this lubricant could result
in harassment from the police and others, and lack of knowledge
about the need for such a lubricant. To help address these problems,
we have developed a low-cost, small-sized lubricant sachet, aimed
at MSM in South Asia, which funding again from DFID in India,
and are currently testing this for user acceptability. The network
of MSM CBOs we have developed, continues to be supported by our
organisation, where we provide technical support around program
management, fundraising and advocacy work. This happens both locally,
and at our training centre we have established in Lucknow, northern
India. We have also developed a resource centre in Lucknow, which
contains a variety of printed resources to help MSM and HIV programming
and policy work, that our partners and others can access. Our
website also contains resources that can be use to inform policy
and programming on MSM and HIV issues.
3.2.2.2 Support for MSM and HIV work by
national governments varies across South Asia. MSM were included
in the second national AIDS plan of India, and are included in
the newly published third plan, though we have a concern that
whilst they acknowledge the benefit of having MSM communities
providing HIV services to themselves (which is essential if appropriate
services are to be providing for many services), this is not always
the approach they will take. We have received many reports of
non-governmental organisations with little or no experience of
working with MSM being contracted to provided HIV services for
MSM in totally inappropriate ways in India. Bangladesh though
whilst allowing work with MSM, have not been supportive in terms
of providing funds for this work. The Nepalese government is showing
signs for supporting the work on MSM there, through the Blue Diamond
Society, an MSM CBO we helped establish. In Pakistan, with support
from the World Bank, we have been undertaking some preparatory
needs assessments, and community development activities, with
a view to establishing MSM HIV services provided by and for MSM.
3.2.2.3 There are other non-governmental
organisations providing services which might reach, or are meant
to reach MSM, but as mentioned above, often they fail to make
these services appropriate, and do not employ suitably knowledgeable
or qualified people.
3.2.2.4 In terms of what appropriate services
are being provided, these can be detailed as:
— Peer education and outreach
to sites where MSM meet for sex. Provision of condoms and sometimes
water-based lubricant and information and advice on safer sex
and other HIV related issues. Befriending, and referral to health
care, social support and other services for MSM.
— Provision of drop-in and safe
social spaces for MSM to meet in.
— Provision of education on safer
sex, and HIV related issues.
— Provision of vocation training.
— Provision of clinical services
to treat sexually transmitted infections and other genito-urinary
complaints. Referral to other health-care services.
— Provision of support around
welfare and human rights, and advocacy around these issues.
3.2.2.5 Very little work is being done with
regards to MSM who are infected with HIV, although we, with our
partner organisations hope to develop community care services
for MSM living with HIV.
3.2.2.6 In terms of estimating the coverage
of services for MSM, we face two major challenges, firstly to
establish the size of any at-risk MSM population, and secondly,
then to assess how many of these at-risk MSM are being targeted
by appropriate and sufficient interventions. Given these challenges,
some work has been done to attempt to give a figure for service
coverage, and coverage estimates vary between 4%[21]
and 45%[22]
of MSM receiving HIV prevention services in India, 77%[23]
receiving HIV prevention services in Bangladesh, 22%[24]
to 15%[25]
receiving HIV prevention services in Pakistan, and 5%[26]
to 36%[27]
receiving HIV prevention services in Nepal. From our estimates
of the numbers of MSM requiring HIV prevention services though
in these countries, and the provision of services we know about,
it is likely that the true coverage is much lower than these figures
suggest. In terms of care and support for MSM living with HIV,
the coverage is almost 0%. Access to treatment for MSM is also
very poor, as they are often discriminated against in access to
healthcare services, and there are no reliable figures for the
number of MSM infected with HIV receiving treatment as far as
we know.
3.2.2.7 We plan, with our partner organisations,
to scale-up coverage of HIV prevention services for MSM in these
countries, and to develop, and scale up support and care services
for MSM, and referral to HIV treatment services, and work to ensure
these HIV treatment services are appropriate for MSM. We will
continue to advocate for the provision of appropriate HIV prevention,
care, support and treatment services for MSM, and work with others
to ensure access to these services.
3.2.3 The role of DFID, the EU, the UN and
NGOs in supporting universal access to HIV prevention, treatment,
care and support for MSM in South Asia.
3.2.3.1 DFID has a role, together with other
bilateral and other donors, and the governments in South Asia,
to ensure those MSM that need HIV prevention, support, care and
treatment services receive them. DFID's role in this can be:
— To help assess the need.
— To develop policies on appropriate
service provision.
— To support these nations to
implement these policies.
— To help these countries tackle
the stigma and discrimination MSM face.
— To provide support to organisations
developing appropriate HIV interventions for MSM in these countries.
— To work with other donors to
ensure that an appropriate knowledge base, supportive policy environment,
and funding sources exist to enable sufficient coverage of necessary
HIV services for MSM in these countries.
3.2.3.2 DFID has played an important role
so far in advocating for work with marginalised communities in
South Asia, and their recent support of an international consultation
meeting on MSM and HIV for the Asia and Pacific (see http://www.risksandresponsibilities.org/
for more details), that we helped organise, show their commitment
to this work. DFID though has an important strategic role it needs
to fulfil, in trying to ensure universal access to prevention,
care, support and treatment with regards to HIV for MSM. DFID
has provided support to our organisation to undertake a strategic
development role around HIV services for MSM in South Asia, although
currently this support is ceasing, and without this continued
support, it is not clear that we can continue to provide this
support to this work, meaning that providing coverage of appropriate
MSM and HIV services in South Asia might well not happen, and
certainly not in a timely fashion (as this role would have to
be reinvented somewhere), without the strategic co-ordination,
advocacy and implementation work we would otherwise do.
3.2.3.3 DFID can, through bilateral aid,
support national governments in implementing their national AIDS
plans, but it is important, that DFID ensure that these plans
are appropriate to the needs of MSM.
3.2.3.4 The EU can, in addition to the GFATM,
and bilateral donors, support community based interventions addressing
MSM and HIV, developing on established models of good practice,
and helping to scale-up interventions.
3.2.3.5 The UN's role, through UNAIDS, and
the organisations that make this up (UNHCR, UNICEF, WFP, UNDP,
UNFPA, UNODC, ILO, UNESCO, WHO, and the World Bank), provide leadership,
policy advice and advocacy, co-ordination, and support to knowledge
generation and management activities, and support specific work
where required, to ensure that male to male sex and HIV are better
understood in these countries, that they are appropriate addressed
in national, and local HIV and AIDS plans, that sufficient financial
resources are available to address MSM and HIV issues identified,
and that this work is undertaken in a timely manner.
3.2.3.6 NGO's can work with the governments,
each other, and external actors, to help develop and advocate
for appropriate policies with regards to MSM and HIV, and where
appropriate, usually through MSM CBOs, provide direct HIV services
to MSM. NGOs that are donors, such as the Bill and Melinda Gates
Foundation, should also address MSM and HIV appropriately, and
support the development of appropriate policies and interventions.
3.3 The extent to which HIV/AIDS policy
and programming is effectively addressing emerging epidemics,
including those in Eastern Europe and Asia. Our knowledge of the
contribution of DFID in addressing these issues, and the role
of the EU, UN and non-governmental organisations.
3.3.1 Evidence we have gained regarding
the incidence and prevalence of HIV amongst MSM in South Asia
suggest that we have both emerging, and well established HIV epidemics
amongst these communities. An analysis of published data on HIV
prevalence figures for India, Pakistan and Bangladesh, suggest
HIV prevalence figures of approximately 10%, 2% and 1% amongst
at HIV-risk MSM in these countries respectively. Published data
though suggests pockets of much higher HIV prevalence in some
areas, although the data on this is sparse and unreliable. We
can conclude though, that in India, we have both an established
and emerging epidemic amongst MSM, and in Pakistan and Bangladesh,
emerging epidemics. It is not clear what is happened elsewhere
in South Asia with regards to MSM and HIV prevalence and incidence.
DFID's policy of addressing marginalised communities, such as
MSM is good in terms of aiming to address MSM and HIV issues,
but what is important, is to ensure the provision of:
— Sufficient coverage of appropriate
HIV prevention services.
— Sufficient coverage of HIV care,
support and treatment services (this synergistically supports
prevention work).
— Support to work tackling stigma
and discrimination around male to male sex and gender issues.
3.3.2 It is not clear how DFID's current
work acts strategically to ensure this.
3.3.3 I do not have any specific evidence
to provide on the EU with regards to this matter, as we have not
worked with them in any depth on this issue yet.
3.3.4 With regards to the UN, UNAIDS has
specifically addressed MSM and HIV in the recent past, and a recent
policy position paper on MSM goes along way to frame a supporting
policy framework for appropriate work around MSM and HIV.
3.3.5 NGOs, both internal to these countries
and externally have a role to play, in terms of developing and
advocating for appropriate policies to address these epidemics,
to develop appropriate interventions, and to support financially,
and in kind these interventions.
3.4 Recommendations for action by the Government
and others.
3.4.1 That DFID needs to ensure a strategic
development approach to MSM and HIV in South Asia, and to support
our work in this regard.
3.4.2 That DFID needs to continue, and increase
support for the development of community based interventions on
HIV prevention, support and care for MSM in South Asia.
3.4.3 That DFID ensure that MSM and HIV
related strategic development and interventions are sustained
in the long-term.
3.4.4 That DFID continues to prioritise
the needs of MSM with regards to HIV, and undertake additional
work, to ensure that their needs are sufficiently well understood,
and that good practice with regards appropriate HIV and related
interventions are recognised and developed.
3.4.5 That DFID regularly review their HIV
development strategy, to ensure it support the universal access
to HIV services for MSM in South Asia and elsewhere in developing
areas.
3.4.6 That DFID ensures the money it spends
on HIV related work is in accordance with its priority for MSM
related work.
3.4.7 That DFID provides a leadership role,
in advocating for a co-ordinated donor response to MSM and HIV
across South Asia and elsewhere.
3.4.8 The DFID encourages UNAIDS to develop
its strategic leadership and brokering role, to ensure coverage
of MSM and HIV services in South Asia and elsewhere.
3.4.9 That DFID develop a focal point on
vulnerable communities, including MSM, to develop good practice
with regards to policy and programme for these communities.
3.4.10 The NGOs, where appropriate develop
MSM and HIV services, and support the development of these programmes,
appropriate policies, and advocate for these.
3.4.11 That this committee asks DFID to
report on the coverage of MSM and HIV related services in South
Asia and other developing areas, and details their strategy in
ensuring universal access to HIV services for MSM in these areas.
Kim Mulji
October 2006
17 See http://www.nfi.net/assessments.htm for more
details. Back
18
Khan OA, Hyder AA. HIV/AIDS among men who have sex with men
in Pakistan. Sex Health Exch 1998; Vol 2: 12-13,15. Back
19
See http://www.nfi.net/assessments.htm for more details. Back
20
http://www.nfi.net/ Back
21
Stover, J, and M Fahnestock. 2006. Coverage of Selected Services
for HIV/AIDS Prevention, Care and Treatment in Low- and Middle-income
Countries in 2005. Washington, DC: Constella Futures, POLICY
Project. Definition used is "percentage of MSM receiving
outreach". Back
22
UNAIDS. 2006. 2006 Report on the Global AIDS Epidemic. Geneva:
UNAIDS. Definition used is percentage of MSM receiving one of
the following services: community outreach programs that included
peer education, exposure to mass media, and sexually transmitted
infection screening or treatment programme. Back
23
Ibid. Back
24
Ibid. Back
25
Ibid reference 20. Back
26
Ibid reference 21. Back
27
Ibid reference 20. Back
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